A Milestone in Hemodialysis: James E. Cimino, MD, and the Development of the AV Fistula

Under-the-skin solution

Briefly, this is how the AV fistula operation is performed: After ad-ministering local anesthesia, the surgeon makes a small incision over the patient's radial pulse, mobilizes the radial artery, and divides and ligates adjacent arterial branches. The surgeon then mobilizes the largest available neighboring vein and brings the vessels side by side. After making longitudinal incisions in corresponding lateral surfaces of both artery and vein, the surgeon performs a side-to-side anastomosis. Today, there are a number of variations of this surgical procedure.

Originally, dialysis was performed the day following surgery. To do this, two sites were selected for venipuncture, usually at the cephalic vein in the upper arm and in the forearm just below the antecubital fossa. Venipuncture is performed at both sites; needles are attached at both sites via a twin dialysis catheter system, fastened to the patient's arm with adhesive tape and attached to an IV drip. The twin catheters are disconnected from the IV drip, and heparin is injected directly into the catheters. The dialyzer tubing and the catheters are connected, the distal needle being used to withdraw blood from the patient's arm for delivery into the dialyzer, and the proximal needle for returning blood to the patient.

First failure, then success

The Cimino team's first AV fistula dialysis attempt failed. Later, they realized it had failed for the same reason the original vein-to-vein technique had failed. “The patient had been prepared so diligently before the procedure that we re-moved too much fluid,” Dr. Cimino says. “His blood pressure was in-adequate for keeping blood flowing through the newly created fistula.” Once the pressure was adjusted, the fistula performed as expected.

After a period of trial and error, Dr. Cimino and his team figured out how to maintain adequate blood flow by using carefully placed tourniquets. They also found that despite their fears, patients' heart functions either remained stable or improved following the creation of a fistula. Soon, most Scribner shunts were replaced with Cimino-Brescia fistulas.

By April 1966, Dr. Cimino had enough experience with the AV fistula needle technique to present the result of his work with 14 patients at the XII Congress of the American Society for Artificial Internal Organs. To his surprise, the audience reacted with complete indifference.

“There was no comment!”

Dr. Cimino recalls, still sounding chagrined decades after the fact. “I thought, they just don't get it.' One doctor from the United Kingdom, who was active in promoting fancy percutaneous punctures of the femoral artery, said, ‘Once you get 100 patients call me.'”

Today, Dr. Cimino can laugh about that brush-off. “A better mousetrap eventually wins people over,” he says. “Our AV fistula proved to be more effective and safer” than the shunt method. “In 1968 I made a grand tour of Europe, going all the way from Naples to Stockholm as guest

of the Swedish Medical Society.”

Dr. Cimino stresses that the success of this program was due to the effort of the entire team, most notably that of Drs. Brescia and Appel. Other important members of the team were Mr. Aboody, Wendy Kolesha, RN (deceased), and Baruch Hurwich, MD (deceased).

Time to move on

After his contribution to the field of hemodialysis was accepted, Dr. Cimino felt it was time to

move on. For one thing, he had long known that he wanted to cut back at the Bronx VA Hospital so he could start a private practice. For another, he had begun to get involved with the House of Calvary, a nursing home in the West Bronx administered by the Dominican Sisters of the Sick Poor. “They took care of terminally ill children and adults,” says Dr. Cimino of the institution that became CalvaryHospital. “At that time Bertram Bell and I had started a practice in White Plains, N.Y. and he knew that the Sisters needed medical assistance. We both grew up in the Bronx and wanted to do something for inner-city people.”

Drs. Brescia and Appel soon joined Dr. Cimino in this new en-deavor. Dr. Cimino began working at Calvary as an attending physician in 1962 while still at the Bronx VA, where he continued as Director of Nephrology Services until 1967 and then of the Hemodialysis Unit until 1970. He continued as a consultant through most of 1978. He also became Calvary's medical director in the mid-1960s and was appointed Director of the Palliative Care Institute in 1994.

In recalling the development of the AV fistula, Dr. Cimino says he had no idea his technique would continue to be popular so many years later. “I thought the real advances were going to be in chemistry,” he says, “and that scientists would develop a pill” to help patients with end-stage renal disease (ESRD).

Although that hasn't happened, Dr. Cimino says the advances that have been made are important. “In those early days we didn't understand the metabolism of calcium and phosphorus; now we can avoid many of the problems we used to have. We also didn't have erythropoietin. Now we do, so we can prevent anemia. And we've learned much more about the power of the parathyroid gland and how to control it.”

In addition to his renal career, Dr. Cimino has taught medical students for over 50 years and taught a course in advanced medical nutrition at New YorkUniversity for more than 20 years. Although he has spent much of his career caring for terminal cancer patients, Dr. Cimino clearly has a soft spot for the ESRD patients he helped many years ago and the ones that, in part because of his efforts, are still alive and functioning well today. “We're not just keeping them alive,” he says. “The fact that we don't think of people on dialysis as being terminally ill speaks to the fact that a great deal of progress has been made.”